Urologist practice structure and quality of prostate cancer care

Provision of prostate cancer services in Tanzania: perspectives from five tertiary hospitals

BACKGROUND

Access to quality prostate cancer services remains a global challenge, particularly in Low- and Middle-Income countries. This is often due to weak health systems that struggle to meet the population's needs. The provision of quality health services to patients with prostate cancer requires a comprehensive approach involving multiple stakeholders and structural inputs. However, few studies have comprehensively assessed the relationship between these structural inputs and prostate cancer treatment outcomes. This study, therefore, aimed to determine the availability of selected structural inputs and descriptions of how they influence the provision of quality services to patients with prostate cancer in Tanzania.

METHODS

We conducted a cross-sectional study using an explanatory sequential mixed-method approach to collect data from five tertiary hospitals providing cancer services in Tanzania. A validated checklist was used to collect information on available structural inputs for prostate services at tertiary hospitals. A semi-structured interview guide was used to conduct 42 in-depth interviews with 20 healthcare providers, five hospital managers, and 17 patients undergoing treatment for prostate cancer. Descriptive analysis was performed for the quantitative data, and thematic analysis was conducted with the aid of NVivo 14 qualitative software for the interview transcripts.

RESULTS

All five assessed tertiary hospitals had inadequate human resources for health to provide prostate cancer services. Only one had 70% of the required HRH, while none had above 40% of the required HRH. Within the hospitals, the skill mix imbalance was severe across cadres. Five themes emerged: inadequate infrastructure, delays in diagnosis, delays in treatment, shortage of human resources for health (HRH), and inefficient organization of prostate cancer services.

CONCLUSION

The findings of this study, underscore the major health system deficiencies for the provision of prostate cancer services in tertiary hospitals. With the increased aging population, strong health systems are vital in addressing conditions of old aging, including prostate cancers. Studies on optimization of the available HRH and infrastructure are needed to improve the provision of prostate cancer in tertiary hospitals as an interim solution while long-term measures are needed for improving the HRH availability and conducive infrastructure.

The immediate effects of private equity acquisition of urology practices on the management of newly diagnosed prostate cancer

INTRODUCTION

Some worry that physician practices acquired by private equity may increase the use of services to maximize revenue. We assessed the effects of private equity acquisition on spending, use of treatment, and diagnostic testing in men with prostate cancer.

METHODS

We used a 20% sample of national Medicare claims to perform a retrospective cohort study of men with prostate cancer diagnosed from 2014 through 2019. The primary outcome was prostate cancer spending in the first 12 months after diagnosis. Secondary outcomes included the use of treatment and a composite measure of diagnostic testing (e.g., imaging, genomics) in the first 12 months after diagnosis. Multilevel modeling was used to adjust for differences in patient and market characteristics. The effect of practice acquisition on each outcome was assessed using a difference-in-differences design.

RESULTS

There were 409 and 4021 men with prostate cancer managed by urologists in acquired and nonacquired practices, respectively. After acquisition, prostate cancer spending was comparable between acquired and nonacquired practices (difference-in-differences estimate $1182, p = 0.36). Acquisition did not affect the use of treatment (difference-in-differences estimate 3.7%, p = 0.30) or the use of diagnostic testing in men who were treated (difference-in-differences -5.5%, p = 0.12) and those managed conservatively (difference-in-differences -2.0%, p = 0.82).

CONCLUSIONS

In the year following acquisition of urology practices, private equity did not increase prostate cancer spending, the use of treatment or diagnostic testing in men with prostate cancer. Future work should evaluate the effects of private equity acquisition on practice patterns and quality over a longer time horizon.

Implications of the Merit-Based Incentive Payment System for Urology Practices

OBJECTIVE

To determine the implications of the merit-based incentive payment system (MIPS) for urology practices. MIPS is a Medicare payment model that determines whether a physician is financially penalized or receives bonus payment based on performance in four categories: quality, practice improvement, promotion of interoperability, and spending.

METHODS

We performed a cross-sectional analysis of urologist performance in MIPS for 2017 and 2019 using Medicare data. Urologist practice organization was categorized as single-specialty (small, medium, large) or multispecialty groups. MIPS scores were estimated by practice organization. Logistic regression models were used to examine the association between urology practice characteristics, including proportion of dual eligible beneficiaries, and bonus payment adjustment as defined by Medicare methodology. Rates of consolidation (movement from smaller to larger practices) between 2017 and 2019 were compared between those who were and those who were not penalized in 2017.

RESULTS

Urologists in small practices performed worse in MIPS and had a significantly lower adjusted odds ratio of receiving bonus payments in both 2017 and 2019 compared to larger group practices (odds ratio [OR] 0.04, 95% confidence interval [95%CI] 0.03-0.05 in 2017 and OR 0.37, 95%CI 0.30-0.47 in 2019). Increasing percent of dual eligible beneficiaries within a patient panel was associated with decreased odds of receiving bonus payment in both performance years. Urologists penalized in 2017 had higher rates of consolidation by 2019 compared to those who were not (14% vs 5%, P <.05).

CONCLUSION

Small urology practices and those caring for a higher proportion of dual eligible beneficiaries tended to perform worse in MIPS.

Urology Workforce Changes and Implications for Prostate Cancer Care Among Medicare Enrollees

OBJECTIVE

To characterize national trends in urologist workforce, practice organization, and management of incident prostate cancer.

METHODS

Using Medicare claims data from 2010 to 2016, we identified all urologists billing Medicare and the practice with which they were affiliated. We characterized groups as solo, small single specialty, large single specialty, multispecialty, specialist, or hospital-owned practices. Using a 20% sample of national Medicare claims, we identified all patients with incident prostate cancer and identified their primary treatment.

RESULTS

The number of urologists increased from 9,305 in 2010 to 9,570 in 2016 (P = .03), while the number of practices decreased from 3,588 to 2,861 (P < .001). The proportion of urologists in multispecialty groups increased from 17.1% in 2010 to 28.2% in 2016, while those within solo practices declined from 26.2% to only 15.8% over the same time period. A higher proportion of patients at hospital-owned practices were treated with observation (P < .001) and surgery (P < .001), while a higher proportion of patients at large single specialty practices were treated with radiation therapy (P < .001).

CONCLUSION

We characterized shifts in urologist membership from smaller, independent groups to larger, multispecialty or hospital-owned practices. This trend coincides with higher utilization of observation and surgical treatment for prostate cancer.